Dosimetry Application Form (UW Health) Dosimetry Application Form UW Health Section 1: Personal IdentificationI will work with* Radioactive Materials X-Ray Producing Machines UW Health Radiation Safety Dosimetry Training Date*For training: 1. Log into U-Connect, go to “Quick Links” 2. Go to “U-Learn” under “General Links” 3. Click the magnifying glass in the upper right corner 4. Search for “UW001409” 5. Register and Launch “Radiation Safety-Dosimetry” 6. Take and pass the short quiz at the end of the course Radiation Safety Dosimetry Training: Date Taken: Date Format: MM slash DD slash YYYY Name* First Middle Last Gender*FemaleMaleDate of Birth* Date Format: MM slash DD slash YYYY Department*Email* Phone*Section 2: Employment InformationI am a:*Full-Time EmployeeTemporary EmployeeStudentEmployment Start Date* Date Format: MM slash DD slash YYYY Employment End DateIf Applicable Date Format: MM slash DD slash YYYY I was previously badged at:*Please check all that apply. UW-Madison UW Hospital UW Medical Foundation None of these; I was not previously badged Other Previously badged at Other - please explain*Other employment involving radiation exposure:*Are you currently or have previously worked with radioactive material or radiation producing machines and have been monitored for radiation exposure?Yes, but not within this calendar yearYes, within this calendar year (copy & paste: https://ehs.wisc.edu/request-for-previous-dose-history-form/ and fill this form out after you submit the application)NoDepartment employed in:*AnesthesiologyCardiologyFamily MedicineGI / UrologyNursingOncologyOrthopedicsPulmonaryRadiologySurgery / Operating RoomsAnesthesiology* ANT - Anesthesiologists - Marie Hendricks Cardiology* CAL - Cardiovascular Laboratory (Cath Lab) - Nicole Heininger CF – Cardiology Fellows – Nicole Heininger EC - Electrocardiography - Suzanne Klingaman SON - ECHO/Vascular Lab - Chris Busse UM - UW Heart – Cardiology - Robert Booth Family Medicine* BLC - Belleville Family Medicine - Erica Dill FM - Wingra Family Medicine - Erica Dill FP1 - Family Practice Northeast - Erica Dill FP2 - Family Practice Verona - Elena Prozorova GF - Generations Fertility Care Clinic - Barb Schulz GI / Urology* GU1 - GI & Urology Clinic - Joy Schluckebier GU3 - GI & Bronchoscopy APC - Sarah Baumann MGI - Meriter GI Physicians – Holly Grundahl Nursing* ACH - American Family Children’s Hospital (P4) - Lisa Keller F66 - F66 Nursing Ward - Jayne McPhail NR1 - Nursing Services - Maggie Grey Oncology* CCU - Cancer Clinic Chemo Unit (Lutathera) - Kendra O’Connell JCC - Johnson Creek Cancer Center - Dawn Klecker RTH - Human Oncology (Radiotherapy) - Jansi Prabakaran Orthopedics* OT - Orthopedics - Beth Lalor RH1 - Rehab – General Services - Janna Studts Wirth Pulmonary* MPU – Meriter Pulmonary – Holly Grundahl Radiology* CT - Computed Tomography (CT) - Donna Juno ESC - East Clinic Radiology Department - Carrie Hamielic DVC - Interventional Radiology Tech's - Jaime Nodolf MAC - Mammography (Breast Center) - Johannah Kereven MP2 - Medical Physics (PET Tracers) - Christine Jaskowiak MP5 - Medical Physics (Molecular Imaging) - Christine Jaskowiak NM - Nuclear Medicine (University Hospital) - Rosalie Hovey-Anderson TNM - Nuclear Medicine (The American Center) - Doug Fiers RD2 - Radiology (Faculty/Fellows) - Holly Jackson RD3 - Radiology (Residents) - Maggi Schrader RD4 - Radiology (UWHC Diagnostic Radiology) - Brett Wehmeyer RD6 - Radiology (UWHC Clinics) - Mary Gehin RT1 - Radiologic Technology - Renee Richardson TAC - The American Center (Imaging / Diagnostics) - Tracy Ellis WSC - West Side Clinic (Diagnostic Radiology) - Karmen Shoys WS1 - West Side Clinic (Bone Mineral Density) - Brenda McCarney Community Radiologists Interventional Radiologists Community Radiologists* FTA - Fort Atkinson Healthcare - Cathy Hovel MAQ - Mauston/ Mile Bluff - Felicia Abbott MEQ - Meriter Hospital - Holly Grundahl RHQ - Richland Center Hospital - Jeremy Pauls TA2 - The American Center - Tracy Ellis UF0 – UWMF Radiology (Medical Imaging/Nuclear Medicine – chest) – Kari Pulfer UF1 - UWMF Radiology (Medical Imaging - collar) - Kari Pulfer Interventional Radiologists* CAL - Cardiovascular Lab: Cath Lab - Caitlin Baxter MAM - Mauston/Mile Bluff - Felicia Abbott MEM - Meriter Hospital - Holly Grundahl RD1 - Radiology (University Hospital) - Holly Jackson VAM - VA Hospital - Diane Meranda VS- Vascular Surgery - Jacqui Huebner Surgery / Operating Rooms* CHS - American Family Children’s Hospital Surgery - Anne Skar MOR - Meriter OR Physicians – Holly Grundahl OR - Operating Rooms – UWHC - Beth Phillips ORO - Operating Rooms – Orthopedics - Denise Dillon ORU – Operating Rooms – Urology – Kristine Wells OS - Outpatient Surgery - Lori Kong SU3 - Surgery (Voice & Swallowing) - Nichole Rauch TSC - Transformations Surgery Center - Erin Hernandez UF2 - Madison Surgery Center - Tammie Schroeder VS - Vascular Surgery - Jacqui Huebner By Signing this Form, I Attest to the Following: I will exchange my badge on time and return it to my badge group leader upon resignation. I certify that the information on this application is correct and complete, to the best of my knowledge. According to DHS 157.22(5), I hereby request and authorize my previous employer(s) to release my dosimetry records. Employee Signature*Signature Date* Date Format: MM slash DD slash YYYY Supervisor Name* First Last Supervisor Signature*Note: Names may be typed into the signature field. Inclusion of the signature or typed name of a UWHC supervisor indicates their knowledge of, and consent to, the submission of this form.